Dear Patient,

The internet has had a profound effect on all aspects of society including the practice of medicine. The dissemination of information and the ability to interact with others is unprecedented in human history.
Not only is this change occurring for major diseases such as cancer treatment , but also in cosmetic surgery and especially rhinoplasty. For this reason, I felt that it would be appropriate to have a separate section for patients utilizing the internet to obtain information about my practice. I should point out that my original web site was put together at the specific request of my internet patients and was completed in only 6 weeks and was up in January, 2004. Due to subsequent requests, we are going to expand the photo gallery to over 100 patients, but this expansion will take time. Therefore, this section is intended to serve as a stopgap measure until the new web site can be completed. For those of you who want to see more of my patients before and after photos, I would suggest that you have your local library borrow a copy of Rhinoplasty: An Atlas of Surgical Techniques which includes over 75 case studies. The majority of the cases shown in this portion of the web site are taken from the Atlas and are included solely for the purpose of patient education. A couple caveats about before and after photographs. First, you will not find “your nose” with the result you want no matter how many cases are shown – the anatomical variations are just too great. Second, no rhinoplasty is perfect – you will always find a flaw if you look hard enough. Third, these are cases that I have done with sufficient follow-up for you to evaluate. Recently, a patient told me that she had not gone to another surgeon because the photos on his web site were the same as on two other surgeons website – the internet does have its downside.

MY PRACTICE

During the 20 years that I have practiced plastic surgery in Newport Beach, CA, I have seen the rhinoplasty portion of my practice go from 25% to now over 90%. At the present time, my practice is probably one of the top 5 rhinoplasty practices in the United States. The reason for this accomplishment is relatively simple – a dedication to achieving what the individual patient wants, a passion for the rhinoplasty operation, and an academic approach to medicine . It is not the result of marketing, glitz, or flash. Rather than hire a publicist, I spent time writing papers on nasal anatomy and physiology during my tenure as Clinical Professor of Plastic Surgery at University of California Irvine. Rather than speaking to the local civic club, I gave lectures on rhinoplasty to my colleagues throughout the United States and in over 15 foreign countries. Rather than putting together fancy brochures, I spent a total of 9 years writing 3 textbooks on rhinoplasty. The most recent, Rhinoplasty: An Atlas of Surgical Techniques, is one of the few single author texts on rhinoplasty surgery by a practicing plastic surgeon, perhaps even the only one. The result of all this hard work is a practice that I enjoy and which affords the rhinoplasty patient with the optimal opportunity to obtain what they want. At the present time, my practice consists of a 60/40 split between primary and revision cases. The majority of my primary cases are referred by former patients who are happy with their result, while most of my secondary cases are referred by other plastic surgeons. Approximately 50% of my practice comes from outside Orange County and almost 25% from outside California.

About a year ago, I noticed that a significant number of patients, age 25-35, were putting down the internet as their referring source. Naively, I assumed that they were researching textbooks and medical journal articles on rhinoplasty and then calling my office for an appointment. Only later, did some of my patients explain that they were obtaining their information from chat rooms and other support groups. Thus far, I feel that chat rooms are valuable provided they remain positive and supportive rather than slip into negativity. It is interesting to note the correlation between patient age and internet usage. Adolescents are a significant portion of my practice, but they are accompanied by their mothers who often have had a rhinoplasty as well as aunts and siblings who provide a familial support group. Thus, the chat room provides both support group and valuable insight throughout the surgical period. Increasingly, secondary patients are using the internet to become more aware of the complexity of their cases.

PRIMARY PATIENTS

Two decades ago, rhinoplasty had the aura of being a relatively simple operation - take down the bump on profile, narrow the nose on front view, and achieve a smaller more refined tip. In truth, the results were spectacular in very selected adolescent girls. Alas, the results were not so good when the same signature nose was performed on those with different anatomy or those who had underlying functional problems. Fortunately, rhinoplasty surgery has undergone a renaissance over the last 20 years with the highlights including the open approach for dealing with more complex tips, recognition of functional factors including the nasal valves, and the realization that numerous techniques are needed to deal with the wide variety of patient problems. The result is that patients can now more often achieve their aesthetic goals while maintaining or improving their nasal respiration. As the results have improved, the operation has become more complex which in turn means that the surgeon must have experience with a broad array of techniques and different patient populations. A few cases should illustrate the wide variety of anatomical problems and differing aesthetic goals which patients can have. Some people will wonder about the dots and rulers – they allow accurate life size enlargements for scientific comparison of before and after photos, and hopefully will not prove too distracting.

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A college student who hated her profile. However, the preop exam indicated that her midvault was narrow and she was at risk of postop nasal obstruction. Result at 1 year following closed rhinoplasty showing a pleasing profile and a natural nose with good respiration, but without a “nose job” appearance.

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A student of Middle Eastern descent who wanted the most refined tip possible despite her thick skin (contrast her tip skin with the previous patient). Result at 2 years following open rhinoplasty with a tip graft for definition.

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A patient of Hispanic descent who wanted a more attractive nose. The result at 1 ½ years achieved with an open rhinoplasty using tip suture technique which I published over 10 years ago and is now used by virtually all rhinoplasty surgeons.

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A patient with significant developmental asymmetry and severe septal deviation – no history of trauma. Result following a closed/open approach that achieved a marked improvement in respiration. Note the subtle changes in her lip height and alignment.

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A patient who complained of a massive bulbous tip and large nostrils. The challenge was to reduce the tip to fit the small dorsum while dealing with the thin skin. I considered this a good result in a difficult case until one day I entered the exam room and found that the tip had regrown! Two years later, I got to do her twin. Results shown at 3 and 5 years postop, respectively.

As the above cases should demonstrate, a successful rhinoplasty requires the surgeon to make a total commitment to achieving excellence in both form and function. Extensive experience with a wide range of surgical techniques is mandatory. Results are rarely perfect and the patient must be able to specify what they want corrected. At all my consultations, I hand the patient a mirror and ask them to tell me what they don’t like about their nose in order of importance. Assuming that these problem areas can be fixed, they become the foundation of the operative plan which is customized to fit each individual patient. Communication between the patient and the surgeon is critical. The result is that most patients can achieve the nose they want within their anatomical limitations and see a dramatic improvement in their self-confidence and appearance.

REVISION (SECONDARY) PATIENTS

Patients use the term “revision” differently than surgeons and yet the discrepancy is quite logical. For the patient, any additional surgery after the primary operation is a “revision” irrespective of who does it. In contrast, surgeons refer to a small “touch up” on a patient upon whom they did the primary as a “revision.” However, when the surgeon does a second rhinoplasty upon a patient who had their primary by someone else, this is called a “secondary rhinoplasty.” Why is this distinction important? Several studies have shown that approximately 87-89% of patients are happy following their primary operation, and that with a revision, it will reach about 93%. This does not mean that 7% had a bad result, but rather that the patient would like an even better result. A truly poor result probably occurs in less than 1% of cases. Surprisingly, patients have a higher satisfaction rate with their result than does their surgeon!

What should the patient do who is disappointed with the result of their primary operation? First, try to clarify in your own mind what you don’t like and what are the areas that you want improved – write the top 3 down in order of priority. Realize that revision surgery is usually not done before 1 year – your nose will get better for a year! Second, set up an appointment with your original surgeon and explain that you are basically happy with the nose, but you would like it even better if a few specific things could be improved. Most surgeons want their patients happy – after all, it is the best referral source they have. Usually, the surgeon will be a bit disappointed , but will wisely see what can be done to turn a good result into a superior result. 95% of the time, it is surgically and financially in the patient’s best interest to have the original surgeon, who knows what was done at the primary operation, do a small revision surgery. Frequently, it’s a question of getting a B result to an A- or A. Just remember – there is not a perfect nose and there has never been a perfect rhinoplasty ever done. There will always be one or two minor things that could be better. Remember – the enemy of very good is perfection, sometimes it is best to stop when you are ahead.

When should you consider seeking another surgeon to do a formal secondary rhinoplasty. The easiest answer is when the result of the original operation is quite poor, a revision was done without significant improvement, or you have lost confidence in the original surgeon. This occurrence is hopefully infrequent. As an intermediate step, you can seek a second opinion from someone in your area before embarking on a secondary rhinoplasty. What are the benefits and problems with a secondary rhinoplasty? First, most patients seeking a secondary rhinoplasty do their homework and find out which surgeons specialize in rhinoplasty surgery and do a large number of secondaries. They also seek several consultations and compare operative plans. What I tell my secondary patients is that our ultimate goal is to achieve a natural appearing and well functioning nose which does not look like it has ever had surgery. I do encourage them to bring me photographs of nasal tips and profiles that they like in order to give me insight into their aesthetic goals. Yet, I do not perform surgery on 50% of the patients who have a consultation seeking secondary surgery. What are the reasons for this low surgery rate? First, many patients are pursuing the “close to perfect nose” where the risks of additional surgery far out ways the rewards. Second, patients can have a few minor imperfections whose correction could result in swapping an old problem for a new one. Third, there are real “end points” and certain “limitations” which preclude surgery.

However, a secondary rhinoplasty can be a truly life restoring event for the patient with a major deformity and an enormous reward for the surgeon willing to accept the challenge. After doing over 1500 major secondary rhinoplasties utilizing virtually every type of graft, I am convinced that these cases are the most challenging in all of plastic surgery. A few examples to illustrate the range of cases.

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A student following a prior rhinoplasty in which the nasal tip skin necrosed resulting in a full thickness scar over the left side of her tip. Result at 1 ½ years with significant improvement.

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Another student whose original operation failed due to her thick skin and very amorphous infantile tip. Result at one year following open approach, scar excision, tip graft and skin redraping. The scarring is still visible inside her nostril and hopefully the skin envelope will continue to tighten around the tip graft for up to 2 years.

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A 60 year old woman following a rhinoplasty with over resection of the dorsum and tip collapse with distortion of the columella. Result at one year with a straighter nose, higher bridge and a more natural columellar/nostril relationship as shown on profile.

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A patient of Asian descent who had suffered a prior infection and extrusion of her silastic implant – a not too infrequent occurrence with any foreign implant ( silicone, medpore, goretex, etc). The severe tip scarring was improved using an open approach with a major columellar strut and tip graft, while the dorsum was augmented using diced cartilage wrapped in fascia – a technique which I have pioneered and lectured on. The critical factor is the use of the patient’s own tissue rather than a foreign implant which will lead to fewer major complications and a more durable long term result in Asian patients.

As the above cases illustrate, the range of secondary deformities is enormous and must be matched by the surgeon’s range of surgical techniques which can only come from experience. There are no short cuts for dealing with the most difficult of noses in patients who have suffered over a long period of time. Whereas there are numerous surgeons who can do a good or very good primary rhinoplasty, there are very few surgeons who have the requisite experience and commitment for correcting difficult secondary noses. Yes the critical observer will always find the flaws in these results. However, for the patient the tears of happiness when the patients see their new natural unoperative appearing nose, and especially the feeling of no longer being deformed makes the imperfections easier to accept.

CONSULTATIONS

Many patients use the internet to acquire information and to find support in chat rooms for helping them go through the entire rhinoplasty process. Some will use it to locate a surgeon in their geographical area who specializes in rhinoplasty. Although over 200,000 Americans will have rhinoplasty surgery each year , there are perhaps only a dozen surgeons who do more than 250 rhinoplasties annually. A certain percentage of primary patients will seek out these rhinoplasty specialists to help them with their “problem” nose ( bulbous tip, thick skin, etc). Often, patients seeking secondary surgery will compare notes on surgeons and their techniques before undergoing another operation. All of this interchange is good and will lead to an improvement in rhinoplasty results as long as it remains positive and supportive.

As an individual surgeon with a busy rhinoplasty practice, I can only do about 300 rhinoplasties a year. Rather than concentrate solely on revisional surgery, I seek to maintain my practice at 30% routine primaries, 30% problem primaries, and 40% secondaries. The routine primaries come from Southern California , usually referred by former patients and word of mouth. The “challenging” primaries are sent by other plastic surgeons or by patients, increasingly via the internet, seeking out a surgeon who can deal with their problem nose (bulbous tip, over projecting tip, thick skin, ethnic nose, etc). Revision cases come from other plastic surgeons and from patients doing their own research. Thus, an increasing number of patients are inquiring about surgery and coming from all over the US and overseas. As a convenience and to simplify the process, it makes sense for many internet patients to send me a brief summary of what they want done and their nasal history plus a few standard photographs before coming to California for a consultation. Why snail mail and not the internet? First and foremost are legal issues. If a surgeon dispenses specific medical advice via the internet, it is mandatory that the physician have a medical license in the state that the patient resides in, not where the physician practices. Second, I want to have time to go over the photos and reflect on each individual patient’s case. Most “internet consultations” are screening consultations done by a patient coordinator or someone other than the surgeon. In contrast, I personally review each patients submission. Third, the demands of answering each e-mail request would take away from providing optimal patient care.

What to do? If you are a primary patient and want to come for a consultation then just call the office and the staff will schedule an appointment. If you are a primary patient who wants me to review your case before coming a long distance, then send the appropriate photographs and history. If you are a revision/secondary patient and live in Southern California then you can schedule an appointment. For secondary patients living outside Southern California, it is best if you send the appropriate photographs and history including the prior operative records if possible. Ultimately, you will need to come to a face to face consultation in order that we can discuss your specific case and allow me to examine the nose in detail.

Send me the best photographs you can take (dark solid background preferred) and at least the following 4 views. Detail in writing your nasal history (emphasize breathing problems, prior trauma and/or surgery) . Then list in order of importance what you want done. Send it to my office. I will review your submission in detail and then a member of my staff will call or write you to let you know if a “nose to nose” consultation is worthwhile.

In conclusion, I hope that this information will prove of value to you as you seek rhinoplasty surgery. From a plastic surgeon’s perspective, I provide each of my patients with an individualized operative plan for achieving their specific goals. As an academic surgeon, I lecture and write extensively on rhinoplasty surgery with the goal of improving all patients results. It is my sincere hope that the internet will lead to an even greater degree of patient happiness for all rhinoplasty patients.

Sincerely

Rollin K. Daniel, M.D.,